Emil Kraepelin in his classic 1921 "Manic-Depressive Insanity" had this to say about what he called "excited depression":

It is here a case of patients who display, on the one hand, extraordinary poverty of thought but, on the other hand, great restlessness. ... Mood is anxious, despondent, lachrymose, irritable, occasionally mixed with a certain self-irony. ...

And here he is expounding on "depressive or anxious mania":

A morbid state arises, which is composed of flight of ideas, excitement, and anxiety. The patients are distractible, absent-minded, enter into whatever goes on round them, take themselves up with everything ...

Unbelievably, the DSM-IV is silent on both anxious depression and anxious mania. The DSM-5, due out in 2013, would change this somewhat, with the new diagnosis of "mixed/anxiety depression," but nearly a century after Kraepelin, the people who should know better can't bring themselves to acknowledge the obvious in mania.

Mixed Depression/Anxiety

Filed under "Depressive Disorders" is the proposed DSM-5 diagnosis of "mixed depression/anxiety." This involves "three or four of the symptoms of major depression" (a straight depression diagnosis requires at least five symptoms). One of the symptoms must include depressed mood or loss of pleasure. The depressive symptoms must be accompanied by "anxious distress."

The draft DSM-5 defines anxious distress as "having two or more of the following symptoms: irrational worry, preoccupation with unpleasant worries, having trouble relaxing, motor tension, fear that something awful may happen."

In essence, the DSM-5 is part-way to acknowledging that anxiety can be both an illness and a symptom of another illness. Depression, psychosis, sleep, and eating and other conditions already share this dual status. Indeed, in this particular area, the DSM-5 harkens back to the pre-modern DSM-I of 1952 and DSM-II of 1968, which viewed much of mental illness as the result of an underlying emotional disturbance called "neurosis." (More serious was "psychosis.")

According to the DSM-II, "anxiety is the chief characteristic of the neuroses." In a manner of speaking, anxiety both drove neurosis and could be one of its main symptoms, along with depression. Back in those days, symptoms were viewed as maladaptive responses to one's surroundings.

In other words, anxiety and depression and mania and even schizophrenia were seen as failures in our ability to cope. As naive as this may appear today, there is considerable merit in the old view that anxiety is inevitably to be found at the scene of the crime in almost any mental illness, whether as the principal or the accessory. Mix despair with anxiety and we're immobilized, unable to pick up the phone. Change it to a racing mind and we're yelling into that same phone, freaked out over some slight disturbance.

In one sense, the world is way too close and immediate, on the other too far and disconnected. One day we're treading water surrounded by thrashing ravenous crocodiles. The next we're Major Toms, a million miles from nowhere, cut off from humanity.

Mixed Mania/Anxiety

The DSM-IV does not recognize this state, and neither would the DSM-5. From a clinical level, mixed mania/anxiety would probably be impossible to diagnose, so why bother? But on a personal level, we need to acknowledge reality. It's easy, really. Simply imagine a state of irrational worry combined with failure to control one's impulses. Thus, you may find yourself fretting about your situation at work. Fairly normal. What's not normal is storming into the boss' office and quitting your job, with no other job lined up. This happened to me. It wrecked my life, but I'm grateful I ONLY quit my job. In the frame of mind I was in, I could have done something much worse.

An additional twist: Walk into any support group, and you will hear participants discussing their "mood triggers." Excessive worry, for instance, may cause you to lose sleep, which makes you a sitting duck for mania. Or it may set off depression, which later sets up mania. Keep in mind, depression and mania never operate in isolation. We are talking about a constant two-step, in this case with an additional dance partner.

My anxiety levels are through the roof. I have just met a wonderful woman who lives [40 miles away] in San Diego. I NEED to pass this test. The inspector asks me to turn on my left signal. I turn on my right signal. It's all downhill from there. FAIL! I feel lower than a snake's belly. I'm a loser, an idiot. The woman I just met is going to dump me for sure. We work it out. She will help me. I book another appointment for August.

Two weeks later, I call her in a panic. I have just discovered DMV videos on YouTube. More than a hundred of them. Ten top reasons drivers fail the test. Something about forgetting that Burma is now called Myanmar. Automatic fail.

I’m never going to pass this test!

Yesterday. I’ve willed my heart down to merely 300 beats a minute. Turn left, the inspector instructs. What did he mean by that? I wonder.

He's scribbling in his clipboard. One turn and already I've given him something to write about! I'm doomed! The test ends. The inspector tells me I have a tendency to overthink and panic. Duh! He tells me I've passed. I passed! I refrain from hugging the inspector.

3 comments:

Lizabeth
said...

Well, I have had the draft DSM-5 list of anxiety, all of it, all my life. It is NOT good when your mother tells you, "You were the most alert and awake baby in the hospital nursery" I always "felt the fear" and pushed myself to do it anyway but I guess I finally burned that ability out when I landed in my first depression

Now nothing pushes my into my nasty hypomanias, I'm BP2, faster than getting anxious about something. Most of my drug cocktail is aimed at controlling anxiety and insomnia and if I have more than one day when it doesn't work I am on the phone to my PNP. I also do relaxation breathing and prayer/meditation daily.

And the people who write the manual are only now getting around to recognizing how badly anxiety can affect people? They should talk to me, I'll give them an earful. Oh, and it physiological--a baby can't be "maladapted to her environment."

Hey, Lizabeth. You nailed it. Yes, exactly. The people working on the DSM-5 should have talked to you. And me. And anyone of us who have lived through this stuff. It would be a much different - and far more accurate - DSM.